ATI RN
NCLEX Questions for Oxygenation Questions
Question 1 of 5
A patient with a tracheostomy tube exhibits difficulty breathing and thick secretions. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B - Perform tracheal suctioning. This action helps clear the thick secretions that are causing difficulty breathing. Tracheal suctioning is necessary for patients with tracheostomy tubes to maintain a clear airway. Encouraging deep breathing and coughing (choice A) may not be effective in clearing thick secretions from the trachea. Administering a bronchodilator (choice C) may help with bronchospasm but does not address the underlying issue of thick secretions. Repositioning the patient (choice D) may provide some relief but does not directly address the problem of airway obstruction due to thick secretions.
Question 2 of 5
A patient with pulmonary embolism (PE) is receiving heparin therapy. What lab result should the nurse monitor closely?
Correct Answer: B
Rationale: The correct answer is B, activated partial thromboplastin time (aPTT). Monitoring aPTT is crucial for patients on heparin therapy to ensure the therapeutic range is maintained for anticoagulation. A prolonged aPTT indicates the desired anticoagulant effect of heparin. Platelet count (A) is important to monitor for heparin-induced thrombocytopenia, not routine monitoring. Prothrombin time (PT) (C) and international normalized ratio (INR) (D) are used to monitor warfarin therapy, not heparin.
Question 3 of 5
Which intervention should the nurse implement for a patient with a chest tube and continuous bubbling in the water-seal chamber?
Correct Answer: D
Rationale: The correct answer is D because checking all connections for a loose fitting is essential in this situation. This step ensures that there are no leaks or disconnections along the chest tube system, which could be causing the continuous bubbling in the water-seal chamber. Clamping the chest tube (Choice A) could lead to a tension pneumothorax and is not recommended. Notifying the healthcare provider of an air leak (Choice B) can be done after checking the connections. Repositioning the tubing (Choice C) may not address the underlying issue of a loose connection.
Question 4 of 5
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Correct Answer: C
Rationale: The correct answer is C: Arrange for the patient's caregiver to be present during the teaching. Rationale: 1. Involving the patient's caregiver promotes better understanding and support for the patient's care at home. 2. Caregivers can assist in reinforcing teaching, ensuring the patient follows instructions. 3. Caregivers can help monitor the patient for any signs of worsening condition or noncompliance. 4. This approach is effective in addressing potential barriers to compliance and continuity of care. Summary of other choices: A: Having the patient repeat instructions may not guarantee understanding or retention of information. B: Teaching just before discharge may not allow enough time for the patient and caregiver to fully grasp and prepare for home care. D: Starting teaching during admission may overwhelm the patient and may not address the need for ongoing support at home.
Question 5 of 5
A patient with asthma is being treated with corticosteroids. Which statement by the patient indicates the need for further education?
Correct Answer: A
Rationale: The correct answer is A because discontinuing corticosteroid therapy abruptly can lead to asthma exacerbation and potentially life-threatening consequences. Patients must not stop corticosteroids abruptly without consulting their healthcare provider. Choice B is incorrect as increasing the dose may be necessary under medical supervision. Choice C is incorrect as increasing the beta-agonist dose can be a part of asthma management. Choice D is incorrect as monitoring for signs of infection is a necessary precaution when on corticosteroid therapy.